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Controller vs. Reliever Medications

Asthma educators divide asthma medications into two broad categories based on how they work: reliever medications and controller medications.

Reliever medications

Reliever medications are usually bronchodilators and are used to quickly relieve bronchospasm. These medications generally do not treat the underlying inflammatory process of asthma.

Reliever medications include:

Short Acting Sympathomimetic ß2-agonist Bronchodilators: albuterol (Proventil®, Ventolin®), pirbuterol (Maxair™), levalbuterol (Xopenex®), epinephrine (Adrenalin®), and others. These medications are quick acting and usually give immediate relief of asthmatic symptoms due to bronchospasm.

Anticholinergic Bronchodilators: ipratropium bromide (Atrovent®, Combivent®) and other similar acting medications. When inhaled, these medications are quick acting bronchodilators, though are generally less potent than ß2-agonists.

Reliever medications can give quick and dramatic relief from bronchospasm-related asthmatic symptoms, and they are also helpful in preventing exercise-induced asthma symptoms. Under certain circumstances, high dose IV corticosteroids and oral corticosteroids may also relieve acute asthma symptoms. However, in general, corticosteroids are used as controller medications in asthma management.

Controller medications

Long term controller medications act by providing long acting bronchodilation and/or have anti-inflammatory action to prevent or diminish the inflammatory process and its consequent increase in airway hyper-reactivity. Some of these medications (e.g. corticosteroids) are primarily directed at the underlying inflammatory mechanism of asthma that leads to chronic symptoms and possibly permanent lung damage.

Controller medications include:

Corticosteroids: Today, corticosteroid asthma medications are probably the most effective controller treatments available because they effectively block or suppress most aspects of inflammation in almost all individuals. These medications are available in the following forms:
a.) Inhaled corticosteroids: budesonide (Pulmicort Turbuhaler®, Symbicort®), triamcinolone (Azmacort®), beclomethasone (QVAR®, Vanceril®), flunisolide (Aerobid®), fluticasone (Flovent®, Advair Diskus®), mometasone (Asmanex®), and others.
b.) Oral corticosteroids: prednisone (Deltasone®), methylprednisolone (Medrol®), and prednisolone. Oral corticosteroids have the same effect as inhaled corticosteroids but also have a higher incidence of side effects.


Mast cell stabilizers:
a.) Cromolyn sodium (Intal®) is strictly a preventive treatment medication and needs to be inhaled two to four times daily. Cromolyn sodium is remarkable in that it is rarely associated with any side effects. This is a great medication when it is effective. However it may be effective in fewer individuals than corticosteroids.
b.) Nedocromil (Tilade®) is similar to Intal® but may have additional anti-inflammatory effects.

Leukotriene modifiers: Leukotriene modifiers, such as zafirlukast (Accolate®) and montelukast (Singulair®), affect only one portion of the inflammatory process and appear to be an effective controller medication for many, but not all, individuals. Unlike corticosteroids, the ability of leukotriene modifiers to prevent remodeling and permanent lung damage is still under investigation but does not appear, at this point, to be as effective as corticosteroids.

Long Acting Sympathomimetic ß2-agonist Bronchodilators: These medications are used together with anti-inflammatory medications for better control of chronic asthma. In particular, individuals with nocturnal asthma and some forms of exercise-induced asthma often benefit from this treatment. Examples of long acting ß2-agonists are salmeterol (Serevent®) and formoterol (Foradil®).

Anticholinergic Bronchodilators: Tiotropium (Spiriva®) is a long acting bronchodilator (24 hours), although it is generally less potent than ß2-agonists. It works well for those with COPD or asthma and COPD.

Methylxanthines: Methylxanthines are theophyllines often used in conjunction with anti-inflammatory medications to provide continuous relief from asthmatic symptoms. Examples include Theo-24®, Uniphyl®, theophylline, and aminophylline.

Combination asthma medication treatments containing both bronchodilator and anti-inflammatory medications currently are available (Advair®) with new combinations to be released (Symbicort®). These medications contain an inhaled corticosteroid and a long acting reliever medication.

Controller medications are used on a daily basis for long term control of chronic asthma even when you have no symptoms. These medications are not particularly effective in the treatment of acute symptoms with the exception of oral or intravenous corticosteroids. Although oral corticosteroids are not quick acting, they are the most powerful treatments and over time can relieve the inflammatory component of a severe, acute asthmatic attack when nothing else will work.